Healthcare Provider Details

I. General information

NPI: 1831652866
Provider Name (Legal Business Name): ANNKATRINE LIEGMANN GATES PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/08/2019
Last Update Date: 04/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

545 CONCORD AVE
CAMBRIDGE MA
02138-1125
US

IV. Provider business mailing address

10 COOLIDGE HILL RD
CAMBRIDGE MA
02138-5510
US

V. Phone/Fax

Practice location:
  • Phone: 617-800-9469
  • Fax:
Mailing address:
  • Phone: 617-642-6454
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number11017
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number11017
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License Number11017
License Number StateMA
# 4
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number11017
License Number StateMA
# 5
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License Number11017
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: